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Emdeon ePayment Enrollmentand Authorization FormSimplifying the Business of HealthcareInstructionsProviders can switch from paper to electronic payments by enrolling in Emdeon ePayment in three easy steps! If you have questions about thisEmdeon ePayment Enrollment and Authorization Form, can’t locate your username or password for the Emdeon EFT Online Enrollment Toolor if you need help accessing Emdeon Payment Manager, please call 866.506.2830 and select option 1.Step 1 - Pick an Enrollment Method and Initiate EnrollmentYou have several options for enrollment. You can enroll online, or simply complete the Emdeon ePayment Enrollment and AuthorizationForm and return it to Emdeon by email, mail or fax to complete your enrollment. Please note, you only need to return pages 2-8 of theEmdeon ePayment Enrollment and Authorization Form. Below includes detailed instructions for each enrollment method.How to Enroll Online (Recommended)Complete the Emdeon ePayment Enrollment and Authorization Form at www.emdeon.com/eft. After yourinformation is verified, you will receive an email with your account information and instructions for completing yourenrollment including setting your Payer preferences and adding bank accounts.How to Enroll Online and Submit the Emdeon ePayment Enrollment and Authorization Form by EmailThis Emdeon ePayment Enrollment and Authorization Form includes form fields enabling you to (optionally) complete it usingyour computer online and insert a digital signature. Email your completed Emdeon ePayment Enrollment and AuthorizationForm as an attachment to [email protected] to Enroll by FaxFax your completed Emdeon ePayment Enrollment and Authorization Form to 615.238.9615.How to Enroll by MailMail your completed Emdeon ePayment Enrollment and Authorization Form to:Emdeon Electronic Payment Service Enrollment RequestP.O. Box 148850Nashville, TN 37214Step 2 - Confirm Deposit to Verify AccountOnce you have completed enrollment, Emdeon will make a small deposit in your designated bank account with the reference note“EFT Enroll”. After this has been deposited into your designated account, please call 866.506.2830 for verification purposes. Uponconfirmation of the deposit amount, if you are an existing Payment Manager user, your services will be enabled under the assignedaccount. If you are a new Payment Manager user, you will be given a username and password for your new account.Step 3 - Start using Emdeon Payment Manager to Search, View, Download and Print ERAsYou may access Emdeon Payment Manager https://www107.medi.com/Portal/AccountLogin.faces to search, view and printyour payment and remittance advice for participating Payers. To see a quick tour of Emdeon Payment Manager, nager/.Page 1 of 8Questions? Call 866.506.2830 (Option 1) for assistance.

Attachment 1: Provider InformationIf you require additional space to add Providers, please reprint or copy this Emdeon ePayment Enrollment and Authorization Form. Onsubsequent pages, please ensure that the Billing Provider numbering is changed.Please note: The information you provide on Attachments 1-5 will be used to facilitate EFT payments to you for all Payers you elect toparticipate with.Check here if you are updating existing enrollment information.Provider #1 (Please Print or Type)Provider NameProvider Federal TaxIdentification Number (TIN) orEmployer Identification Number (EIN)StreetCityState/ProvinceZIP Code/Postal CodeTelephone NumberFax NumberEmail AddressProvider #2 (Please Print or Type)Provider NameProvider Federal TaxIdentification Number (TIN) orEmployer Identification Number (EIN)StreetCityState/ProvinceZIP Code/Postal CodeTelephone NumberFax NumberEmail AddressProvider #3 (Please Print or Type)Provider NameProvider Federal TaxIdentification Number (TIN) orEmployer Identification Number (EIN)StreetCityState/ProvinceZIP Code/Postal CodeTelephone NumberFax NumberEmail AddressPage 2 of 8Questions? Call 866.506.2830 (Option 1) for assistance.

Attachment 2: Provider Contact InformationEmdeon will only release information to the authorized individuals listed in this section.Provider Contact Name (Representative #1)NameTitleTelephone NumberEmail AddressProvider Contact Name (Representative #2)NameTitleTelephone NumberEmail AddressProvider Contact Name (Representative #3)NameTitleTelephone NumberEmail AddressProvider Contact Name (Representative #4)NameTitleTelephone NumberEmail AddressPage 3 of 8Questions? Call 866.506.2830 (Option 1) for assistance.

Attachment 3: Financial Institution InformationIf you need to add more than three bank accounts, please reprint this page. On subsequent pages, please ensure that the Bank Accountnumbering is changed.For Aetna EFT enrollment only: If you have more than one bank account to enroll, please fill out a separate enrollment form foreach account and include a bank letter or voided check for each account.Financial Institution Account #1Financial Institution NameStreetCityState/ProvinceZIP Code/Postal CodeFinancial Institution Account Owner NameType of Account at Financial InstitutionFinancial Institution Routing NumberProvider’s Account Numberwith Financial InstitutionFinancial Institution Account #2Financial Institution NameStreetCityState/ProvinceZIP Code/Postal CodeFinancial Institution Account Owner NameType of Account at Financial InstitutionFinancial Institution Routing NumberProvider’s Account Numberwith Financial InstitutionFinancial Institution Account #3Financial Institution NameStreetCityState/ProvinceZIP Code/Postal CodeFinancial Institution Account Owner NameType of Account at Financial InstitutionFinancial Institution Routing NumberProvider’s Account Numberwith Financial InstitutionPage 4 of 8Questions? Call 866.506.2830 (Option 1) for assistance.

Attachment 4: Payment Routing InformationEmdeon will distribute your funds in accordance to the information provided in this Attachment.Instructions for completing Table 1 within Attachment 4:1. Review the list of participating payers listed in Tables 2, 3 and 4 within Attachment 4.2. Specify which payers you wish to receive claims payments via EFT by listing the Payer ID and Payer Name within Table 1 below.3. Specify the appropriate Billing Provider # for each selected payer as listed in Attachment 1.4. Within Table 1, list the Supplemental Provider ID if required. Payers listed within Table 3 require this additional information.5. Specify the appropriate Bank Account # for each selected payer as listed in Attachment 3.Table 1: Payment Distribution Instructions by Banking Account and PayerPayer IDPayer NameBilling Provider #(Attachment 1)SupplementalProvider IDBank Account #(Attachment 3)(e.g.) 61124ABC Health Plan#1N/A#1Page 5 of 8Questions? Call 866.506.2830 (Option 1) for assistance.

Attachment 4: List of Enrolled PayersTo simplify enrollment, list ALLTIN in the Payer ID section of Table 1 within Attachment 4 to indicate your enrollment with all currentlyenrolled Payers that do not require additional information.Table 2: Direct Payment PayersThe payers listed below are offering to distribute EFT payments directly to you and not through Emdeon. If you select a payer below, thatpayer will pay you directly and Emdeon shall not be involved in any of their payment transactions. As such, Emdeon makes no representationsor warranties regarding the payment services provided by the payers set forth below.Payer ID Payer areFirstAdditional Provider IDRequired/Optional (R/O)NPI - (R)Legacy PIN – (R)NPI – (R)and ProviderGroup NumberCoventry Health Care Tax ID - (R), NPI - (O)Humana Inc.MHNetN/AAdditional RequirementsProvide a voided check or banking letter (Photocopies are acceptable). Ensurethe routing and account information on the check matches the bank account you designate toreceive EFT payments from Aetna. If you are providing a banking letter instead of a voided check,please ensure it is printed on your bank’s letterhead and includes your routing number, accountnumber, the account holder’s name and is signed by an authorized bank representative.Providers must enroll using Amerigroup assigned Provider Identification Number. ERA is onlyavailable with EFT enrollment.Providers must enroll or be enrolled for Electronic Remittance Advice (ERA) when selectingYesNoCareFirst EFT. Are you currently setup for ERAs with CareFirst?If you are not yet enrolled and want to enroll for both ERA and EFT from CareFirst please check thefollowing box. (You will receive CareFirst ERAs through Emdeon if this box is checked.)qqqDoes the bank account you listed in Attachment 3 apply to all facilities/providers under this Tax ID? Yes No If no, please specify names and NPIs that should be set up for EFT.Providers must enroll or be enrolled for Electronic Remittance Advice (ERA) when selectingYesNoHumana EFT. Are you currently setup for ERAs with Humana?If you are not yet enrolled and want to enroll for both ERA and EFT from Humana please check thefollowing box. (You will receive Humana ERAs through Emdeon if this box is checked.)qqqTax ID - (R), NPI - (O) Does the bank account you listed in Attachment 3 apply to all facilities/providers under this Tax ID? Yes No If no, please specify names and NPIs that should be set up for EFT.Table 3: Payers That Do Not Require Additional InformationPayer 2283906569493704083727275276Payer NameAll currently listed Payers that only require TINAdministrative Concepts, IncAmerican Family Insurance GroupAmerican Republic World Insurance GroupBluegrass Family HealthCentral Reserve Life Insurance CompanyCommunity First Health PlansContinental General/Provident American Life and HealthContinental ProvidentCUPDental Care PlusDental SelectEverenceFirstCare HealthFoundation for Medical Care of Tulare and Kings CountriesGuardian Life Insurance CompanyHCH Administration (IL)Health Alliance Medical PlansJohn Alden Life Insurance CompanyLovelace LHP - Brokers OnlyLovelace LINC - Brokers OnlyMennonite Mutual AidOhio Benefit AdministratorsParamount HealthPreferred Care PartnersSanfordSouth Indiana Health Operations - HMOTeacher’s Health TrustTexas Children’s Health Plan - CHIPTexas Children’s Health Plan - STARTime Insurance CompanyTower Life Insurance CompanyUnion Security Insurance CompanyWells Fargo TPAWorld CorpPage 6 of 8Questions? Call 866.506.2830 (Option 1) for assistance.LOBN/AD, MMMMMMM, HMMDDD, MM, H, DMD, MMMMBrokersBrokersM, HMMMMMMMMMD, MMD,MMLOBMM, HM, HM, HM, HM, H

Table 4: Payers That Do Require Additional InformationTo simplify enrollment, list ALLNPI in the Payer ID section of Table 1 within Attachment 4 to indicate your enrollment with all currently enrolled Payers that donot require additional information.Payer gend Payer NameAll currently listed Payers that require TIN NPIAccess DentalAdvocate Health PartnersAffinityAmeriBenAmeriHealth Mercy Health PlanAmeriHealth Northeast LLCArbor Health PlanBlue Cross Blue Shield of VermontBravo HealthCareFirst Administrators/NCASCBHNP- AmerihealthCeltic InsuranceCentral Reserve Life Insurance CompanyContinental General Insurance CompanyEmployee Plans, LLCFlorida True Health, IncCIGNA - Central Reserve Life Insurance CompanyCIGNA - Continental General Insurance CompanyCIGNA - Great American Life Insurance CompanyCIGNA - Loyal American Life Insurance CompanyCIGNA - Provident American Life & Health Insurance CompanyCIGNA - United Teacher Associates Insurance CompanyGenworth Wakely LOBGreat American Life Insurance CompanyHawaii Medical Assurance Association (HMAA/HWMG)Health First Health PlansHealth PlusHealthcare Partners IPAHorizon NJ HealthIndependent HealthAdditional Provider IDRequired/Optional (R/O)Keystone Mercy Health PlanLA CareLoyal American Life Insurance CompanyMDWise Hoosier AllianceMed3000 PEDICARE TITLE 19Med3000 CMS TITLE 21Med3000 CMS SAFETY NETMed3000 CMS EARLY STEPSMed3000 PEDICARE TITLE 21Med3000 CMS TITLE 19 REFORMMedBenNetwork HealthPassport Health PlanPhysicians United PlanPremier DentalProvident American Life & Health Insurance CompanySCAN Health PlanSecure Horizons Lifeprint ArizonaSelect Health of South CarolinaSierra Health ServicesSterling LifeTML Intergovernmental Employee BenefitsUnited Healthcare Student ResourcesUnited Teachers Associates Insurance CompanyUpper Peninsula Health PlanWindsor Medicare ExtraZepherellaViva HealthLegacy ID – (R) indicates the Legacy ID (payer assigned provider ID) is required by the payerLegacy ID – (O) indicates the Legacy ID (payer assigned provider ID) is not required by the payerNPI – (R) indicates the National Provider ID is required by the payerNPI – (O) indicates the National Provider ID is not required by the payerBrokers – Agency ID – (R) indicates the agency ID is required for brokersLOB: Line of business for which the payer is enabled for EFT with EmdeonD – DentalM – MedicalP – PharmacyH – HospitalPage 7 of 8Questions? Call 866.506.2830 (Option 1) for assistance.NPI – (R)NPI – (R)Legacy ID – (R)Legacy ID – (O)NPI – (R)Legacy ID – (R)Legacy ID – (R)Legacy ID – (R)NPI – (R)NPI – (R)NPI – (R)Legacy ID – (O)NPI – (R)NPI – (R)NPI – (R)Legacy – (R)NPI – (R)NPI – (R)NPI – (R)NPI – (R)NPI – (R)NPI – (R)NPI – (R)NPI – (R)NPI – (R)Legacy ID – (O)NPI – (O)Legacy ID – (R)Vendor ID – (R)Legacy ID – (R)Providers – Tax ID – (R)Pharmacy – Payee ID – (R)Legacy ID – (R)Legacy ID – (R)NPI – (R)Legacy ID – (R)Provider ID – (R)Provider ID – (R)Provider ID – (R)Provider ID – (R)Provider ID – (R)Provider ID – (R)NPI – (O)Provider ID – (R)Legacy ID – (R)Legacy ID – (O)Providers – NPI – (R)Brokers – Agency ID – (R)NPI – (R)Vendor ID – (R)NPI – (O)Legacy ID – (R)NPI – (R)NPI – (R)NPI – (R)NPI – (R) Tax ID – (R)NPI – (R)NPI – (R)Vendor ID – (R)NPI – (O)Vendor ID – (R)LOBN/ADMMMM, HM, HM, HM, HMM, HM, HM, HM, HM, HM, H, DM, HM, HM, HM, HM, HM, HM, HM, HM, HD, MM, HMMM, HMM, HM, HM, HM, HM, H, DM, H, DM, H, DM, H, DM, H, DM, H, DM, H, DMM, HMDM, HM, H, DMM, HMD, MD, MM, HM, HMM, HMM, H

Attachment 5: Emdeon ePayment Enrollmentand Authorization Form AcknowledgementBy signing below, Provider acknowledges that it is read, agrees that it is subject to and agrees to comply with the Emdeon General Termsand Conditions, the Business Associate Terms, the ePayment Services Addendum and the Privacy Policy for Emdeon.com. To view theEmdeon General Terms and Conditions, the Business Associate Terms and the ePayment Services Addendum please visit:www.emdeon.com/epayment/terms. To view the Privacy Policy for Emdeon.com, please visit www.emdeon.com/privacy. In addition,by signing below, Provider represents and warrants that all of the information that it is providing to Emdeon is accurate and complete. Infurtherance of the ePayment Services, Provider authorizes Envoy LLC or one of its Affiliates to initiate ACH debit and credit entries to theabove account(s) at the above depository financial institution(s). Provider acknowledges that the origination of ACH transactions to the aboveaccount(s) must comply with the provisions of U.S. law. Provider also acknowledges that in the provision of the ePayment Services, theProvider’s enrollment information will be made available to the Payers making payment to the Provider through the ePayment Services.If Provider desires to revoke or modify the authority of any Authorized Representative or add additional Authorized Representatives, Providermust execute and deliver to Emdeon a new Attachment 2. Letters or other forms of communications will not be accepted. Any subsequentAttachment 2 supersedes any previously submitted Attachment 2. CURRENT AUTHORIZED REPRESENTATIVES NOT ON THE NEWATTACHMENT WILL NOT BE RECOGNIZED.Please check the box below if you have elected to receive payments from Direct Payment Payers.I hereby authorize Direct Payment Payer(s) to initiate ACH credit and debit entries to the account(s) listed in Attachment 3 for all benefitspayments. Provider acknowledges that the origination of ACH transactions to the above accounts must comply with the provisions of U.S.law. This agreement will remain in effect until I notify the Direct Payment Payer(s) of the desire to cancel or change this service or until I amnotified by Direct Payment Payer(s) that this service has been terminated. I understand I must allow reasonable time for my instructions tobe executed.As required by 42 C.F.R. 455.18 and 455.19, I understand in accepting electronic payment that such payment may be from Federal and StateFunds and any falsification or concealment of a material fact may be prosecuted under Federal law.IN WITNESS WHEREOF, the parties have caused this Emdeon ePayment Enrollment and Authorization Form to be executed by theirrespective duly authorized representatives.Provider Contact InformationNameTitleTelephone NumberEmail AddressAuthorized SignatureDaterev 4.13Page 8 of 8Questions? Call 866.506.2830 (Option 1) for assistance.

76048 Texas Children’s Health Plan - CHIP M 75228 Texas Children’s Health Plan - STAR M 39065 Time Insurance Company M 69493 Tower Life Insurance Company D, M 70408 Union Security Insurance Company M 37272 Wells Fargo TPA D,M 75276 World Corp M Payer Name Additional Provider ID Payer I